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Information for All Providers...........

Document level processing bundles multiple lines submitted on a claim and pays at the claim level assigning the same transaction control number (TCN) to each line. When the TCN is used to submit an adjusted claim, all lines that were assigned that TCN will be impacted by the transaction.

Document level processing impacts both electronic and paper claims submitted with multiple claim lines by fee-for-service providers as well as rate-based home health and clinic providers.

To adjust (replace) a previously paid claim, providers must know what lines were originally paid under the TCN.

Providers are responsible to correctly resubmit all claims that may be voided as a result of improperly adjusting previously paid claims

Take Note:

If an adjustment is submitted without one or more of the lines paid from the previous claim, those omitted lines will be voided and the money taken from the check issued for the weekly payment cycle
in which the void is processed.

If the amount of the voided claims exceeds the total paid claims for that cycle, a negative balance is placed on the provider's file and the payment for any subsequent claims will be used to reduce the negative balance to zero before any further checks will be issued.

Submitting multiple adjustments without understanding document-level processing can result in unintended voided claims that may create a negative balance for the provider.

Suggestions

Fee-for-service providers are urged to familiarize themselves with the instructions and examples in the Billing Guidelines section of their provider manual before submitting claim adjustments.

Providers who have a large number of adjustments to submit may want to initially submit only one claim to ensure the adjustment processes as the provider intended.

Claims failing eMedNY edits 00127 (Medicare Paid Amount Reported Less Than Reasonable Amount), and 01283 (Upper Dollar Limit Exceeded) will pend for review prior to final adjudication. The status of electronic claims pended for these edits are located on the provider's Supplemental Remittance file, sent with the HIPAA-compliant (835) remittance.

If the claim(s) is denied upon final adjudication, the corresponding HIPAA codes that will be reported on the 835:

00127: Adjustment Reason Code 16 and Remittance Remark Code MA92

01283: Adjustment Reason Code A1 and Remittance Remark Code N14.

If the claim(s) is pended, the corresponding claim status (277 or via ePACES) codes are:

If you have claims pended for the above edits and you can provide documentation (i.e., Medicare Explanation of Medical Benefits (EOMB)) to support that your billing was appropriate, please follow these instructions:

Documentation should be sent to the Edit Review Panel for these edits ONLY.

Documentation sent for any other edits will be returned to the provider.

If you receive a paper remittance from Medicaid, and would like Computer Sciences Corporation (CSC) to review the claim, circle the Transaction Control Number (TCN) of the claim(s) pending for edit 00127 or 01283. If you receive an electronic remittance from Medicaid, you must indicate the TCN of the Medicaid claim on the Medicare EOMB.

On the Medicare EOMB, circle the information corresponding to the claim(s) to be reviewed.

Documentation that is incomplete, illegible or unusable will be returned to the provider. CSC staff will review the documentation and adjudicate the claim(s) accordingly through the regular claim processing system. The adjudicated claims will appear on the provider remittance statement.

Providers making inquiries or requesting billing training by Regional Representatives should contact CSC by calling the eMedNY Call Center at:

Policy and Billing Guidance...........

Medicaid regulations at 18 NYCRR § 540.6(e)(6) require a provider to pursue any available commercial insurance prior to submitting a claim to Medicaid. This means that providers must bill available commercial insurance, but are not required to contract with all available commercial insurers.

The Patient Responsibility Amount is the Amount for which the patient would be responsible if he or she did not have additional insurance.

This amount varies depending on whether or not the provider contracts with a commercial insurance payer.

Until February 1, 2007, the Medicaid Program paid the difference between the commercial insurance payment amount and the Medicaid rate or fee.

Effective February 1, 2007, Medicaid pays the lower of either:

the Medicaid rate minus the insurance payment, or

the Patient Responsibility Amount.

When a provider contracts with a commercial insurance payer, the Medicaid Program pays the difference between the commercial insurance payment amount and the commercial insurance patient coverage amount. Essentially, Medicaid pays the commercial insurance co-payment, deductible and/or co-insurance.

When a provider does not contract with a commercial insurance payer, Medicaid pays the patient responsibility. In this case, this is the difference between the commercial insurance payment amount and the provider's usual and customary charge, up to the Medicaid rate.

Background Information

All Medicaid payments are subject to federal and State Medicaid subrogation rules. This means that the Medicaid Program "stands in the shoes of the enrollee" with regard to that commercial insurance policy, and is entitled to receive the value of those policy benefits either directly or through a reduction in the amount otherwise payable to the provider.

The Centers for Medicare and Medicaid Services has specifically instructed State Medicaid agencies to limit payments in these circumstances, per Section 3904.7 of the State Medicaid Manual:

"...The provider's agreement to accept payment of less than its charges constitutes receipt of a full payment for its services, and the insured has no further responsibility.
Medicaid is intended to make payment only where there is a recipient legal obligation to pay..."

Where the enrollee is obligated to pay the provider a co-payment (that is, the Patient Responsibility Amount), the federal subrogation requirements obligate Medicaid to pay that amount to the extent that total payment to the provider does not exceed the Medicaid payment amount.

Note: If the Medicaid payment is lower than the commercial insurance payment, Medicaid pays nothing. This policy is unchanged.

Billing Guidance

If a clinic provider has received reduced payments, but is not contracting with a commercial insurance payer, the clinic should enter the difference between the commercial insurance payment and its usual charge in the patient responsibility field on the claim form.

If using 837I, 837D or 837P claim formats, the difference between the commercial insurance payment and the clinics usual charge should be represented in:

Loop 2320 CAS segment using "PR" for Patient Responsibility in CAS01; and

The Centers for Medicare and Medicaid Services has approved coverage of additional procedures and services performed during a family planning visit as well as follow-up procedures and treatment for "limited medical conditions" diagnosed during a family planning visit. Additionally, New York State has authorized coverage of the follow-up treatment of specific sexually transmitted infections (STIs).

Claims for these services and procedures may be submitted on or after March 27, 2008, for service dates retroactive to July 1, 2007.

Additional Services Performed During a Family Planning Visit

To bill for these services, claims must contain:

A "Y" in the Family Planning Box.

A primary ICD-9CM diagnosis code in the V25 series.

The appropriate CPT-4 code for the procedure(s) or medical supply (Table A).

Follow-up Treatment of Sexually Transmitted Infections

To bill for these services, claims must contain:

If the primary reason for the follow-up visit is for treatment of a STI, the primary ICD-9 CM diagnosis code must be the STI (Table C).

If the primary reason for the follow-up visit is for family planning and STI treatment is secondary, the primary ICD-9CM diagnosis code must be in the V25 series and the secondary diagnosis code must be the specific STI (Table C).

A CPT-4 procedure code for an evaluation and management follow-up visit (Table E).

Clinic claims must also include a clinic rate code.

Questions? Please call the Bureau of Policy Development and Coverage at (518) 473-2160.

Table AAdditional CMS-Approved CPT-4 Codes for the FPBP

58100

77081

82247

82948

85002

85378

86901

87486

88173

99386

58340

77083

82270

82950

85004

85576

87015

87495

88302

99394

71020

80048

82550

82951

85007

85610

87040

87620

88305

99395

74000

80053

82553

83001

85018

85651

87075

87621

88307

99396

76830

80061

82565

83002

85027

85652

87077

87797

93307

A4931

76856

80076

82570

83690

85032

85730

87088

87801

99384

J7306

76857

81015

82575

84075

85045

86580

87164

87899

99385

J7307

77078

82040

82670

84144

85049

86632

87166

88143

77079

82043

82677

84146

85210

86687

87206

88152

77080

82150

82947

84443

85300

86900

87255

88161

Notes:

J7307 is the new CPT code for Implanon, and replaces code S0180, effective January 1, 2008.

The CPT-4 procedure codes above are in addition to the family planning codes published in the
May 2007 Medicaid Update found at:

Do You Have a Question About the Medicaid Program?

Please note the following changes relating to HCPCS coding, Wheeled Mobility and Labor fees and a new process for some commonly requested miscellaneous equipment.

HCPCS Changes

Effective for order dates on and after January 1, 2008, the following code has been discontinued:

E2618 #Wheelchair accessory, solid seat support base (replaces sling seat), for use with manual wheelchair or lightweight power wheelchair, includes any type mounting
hardware.

For a manual wheelchair:

If a new folding wheelchair is being delivered use code E0992.

If a replacement is needed, use E0992, with "RP" modifier.

A solid seat support base is included with the payment for a rigid manual wheelchair; no additional payment will be made.

For pediatric seating:

A solid seat support base is included with the payment for planar and contoured pediatric seating codes E2292 and E2294: no additional payment will be made.

If a replacement solid seat support base is needed, use the wheelchair code with the RP modifier.

For a power wheelchair:

A solid seat support base is included with the payment for a new wheelchair: no additional payment will be made.

If a replacement solid seat support base is needed, use wheelchair code with the -RP modifier.

Fee Schedule Updates

Effective for dates of service on and after January 1, 2008 the fee for E1161 #Manual adult size wheelchair, includes tilt in space is $2287.24.
The fee includes any transport option.

Effective for dates of service on and after January 1, 2008 the fee for E0992 #Manual wheelchair accessory, solid seat insert will be $112.28. The code describes a solid seat support base and the fee includes any type mounting hardware.

New Process for Commonly Requested Miscellaneous Items

Effective for order dates on and after January 1, 2008, a new process is established for commonly requested items categorized as E1399 Durable medical equipment, miscellaneous.

A UESS is covered when the medical need for positioning in a wheelchair cannot be met with less costly alternatives such as any combination of a safety belt, pelvic strap, harness, prompts, armrest modifications, recline, tilt in space or other existing or potential seating or wheelchair features.

Upper Extremity Support System & Rolling Recline Shower Commode Chair

An upper extremity support system (UESS) and rolling recline shower commode chair will not be subject to medical review and will have maximum reimbursable amounts (MRA) assigned to them.

Documentation should include the patient's ability to effect knowing and purposeful position changes using the UESS.

UESS dimensions should not exceed the positioning length of the forearms (e.g., 12-15"). A UESS featuring enhancements (i.e. rims, lips, padding) or dimensions greater than
medically needed for upper extremity support alone will not be approved.

A wheelchair tray is not considered a seating tray and will not be approved for completion of activities of daily living. The MRA for a UESS, any type, includes all modifications, padding and mounting hardware is $199.88.

A rolling recline shower commode chair is covered when recline is necessary to complete hygiene needs and the patient either has positioning needs that cannot be met by upright and fixed angle chair or the patient's postural control requires recline feature.

The MRA for a rolling recline shower commode chair, any size, including safety belt and padded headrest with any type armrest is $390.45.

A medically justified foot rest may be billed separately using code E0175 #Foot rest, for use with commode chair, each (one or two piece).

E1399 will be used for the UESS and rolling recline shower commode chair to obtain a prior approval number without submission of medical documentation using the following procedure:

DME provider obtains valid order and medical documentation (to maintain in their records for audit purposes) from the ordering practitioner;

DME provider submits a prior approval request containing a copy of the valid order and either a manufacturer's price quote or the item's make and model;

These items must be submitted singularly on a separate prior approval from all other prior approval items;

The DME provider will be issued a prior approval priced up to the established MRA and may bill Medicaid upon dispensing.

Reviewers will contact a requesting DME provider and ordering practitioner for clarification if same or similar items have recently been provided and/or currently being requested by another provider.

Labor and Repairs

Effective for dates of service on and after January 1, 2008, the fee for E1340 #Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes, L4205 Repair of orthotic device, labor component, per 15 minutes and L7520 Repair of prosthetic device, per 15 minutes (includes evaluation) will be $10.00.

More than two hours of repair requires prior approval.

Billing instructions:

E1340 is reported when:

No specific code exists to describe the item in need of service, and

The charge for replacement parts and related labor exceeds the fee for A9900.

The -RP (Repair and replacement) modifier should be reported when a specific code and fee is listed in the
DME Provider Manual for the item requiring service.

E1340 must not be billed in conjunction with the specific code plus -RP for repair and replacement of the same item. For listed codes, the labor component of repair and replacement is included in the payment resulting from use of the specific listed code with the -RP.

Labor is included in the payment for new equipment and components. E1340 and -RP must not be billed in conjunction with new equipment or components. The only exception is when over two hours of labor is required for a skilled technician to perform complex disassembly and assembly to add a new component to existing equipment dispensed previously.

Repairs and replacement covered under the manufacturer's warranty are not to be billed.

When repair and replacement is performed by a manufacturer, Medicaid pays the Medicaid provider the line item labor cost on the manufacturer's invoice and the applicable Medicaid fee on the parts. If labor and parts charges are not separately itemized on the invoice as required by 18NYCRR 505.5, the Medicaid provider is not entitled to a markup on the cost of parts and will only be paid the manufacturer invoice
cost of parts and labor.

Effective for dates of service on and after January 1, 2008 refer to the cross-reference procedure code for billing a standard gastrostomy tube. Do not bill B4086 for dates of service after December 31, 2007.

Effective with order dates on and after January 1, 2008, use B4088 for a low-profile gastrostomy tube. Prior approvals granted with order dates prior to January 1, 2008 under T5999 for low-profile gastrostomy tubes will be honored for the approved period of service, after which B4088 should be reported.

Discontinued Codes

Cross-Reference Procedure Code

Price

B4086#

B4087 #Gastrostomy/jejunostomy tube, standard, any material, any type, each

$ 22.89

(With the addition of B4088, the low profile tube no longer is billed using T5999, which continues to be active for other supply items.)

B4088 #Gastrostomy/jejunostomy tube, low-profile, any material, any type, each (for patients who cannot tolerate the size of a standard gastrostomy tube or who have experienced failure of a standard gastrostomy tube.

This code is for replacement in the patient's home and should not be billed when the tube is replaced in the physician's office, ER or facility with an all inclusive rate This kit includes tube/ button/ port, syringes, all extensions and/or decompression tubing and obturator if indicated).

# = DVS AUTHORIZATION REQUIRED

$134.58

Effective for dates of service on and after January 1, 2008 the allowable monthly quantity on this code will increase from 100 to 200 units per month:

A4221 is used for all supplies necessary for maintenance of drug infusion catheters and external pumps and/or supplies necessary for the administration of drugs (except insulin)
not otherwise listed in the Pharmacy Provider Manual. Prior approval is required only when the total charge for supplies not otherwise listed exceeds $200.00 (200 units) per month.

Persons eligible for Family Health Plus who have access to cost effective health insurance through their employer are now eligible for premium assistance through the

Family Health Plus Premium Assistance Program.

When a person enrolls in the Premium Assistance Program, the State will pay or reimburse:

the employee's share of the insurance premium;

the employee's deductible, coinsurance and any co-payment amounts that exceed those currently required by Family Health Plus for persons eligible and enrolled in the program; and

services covered by Family Health Plus but not covered by the employer's plan (subject to the requirements below).

Individuals without access to employer-sponsored health insurance are not impacted by this change in eligibility rules.

Program Eligibility Review

Individuals with access to employer-sponsored health insurance will be asked to provide information about the available coverage to their local social services district (in New York City, the Human Resources Administration).

If the local social services district determines that the employer-sponsored health insurance is qualified and cost effective, the individual will be required to join the employer-sponsored health plan at the earliest opportunity.

Payment for Services Not Covered by the Employer-Sponsored Health Plan

Enrolled individuals will receive a Medical Assistance Benefit Card which they may use to obtain Family Health Plus benefits not covered by their employer-sponsored health insurance from any enrolled Medicaid provider on a fee-for-service basis. Medicaid providers must verify eligibility prior to provision of these services.

The Medicaid Eligibility Verification System (MEVS) response for these enrollees will be "Other" or "Additional Payer". The commercial policy number, plan code and plan address will also be provided. For additional information please refer to your MEVS Provider Manual located at:

The following table, developed by the National Medicare Training Program, is designed to help you determine which part of Medicare covers a drug in a particular situation, assuming all other requirements are met, e.g., a drug must still be medically necessary to be covered. It provides general guidance only and does not cover all possible situations.

Type of Coverage

Care Setting*

Drug Type

Covered By**

Comments

Original Medicare and a Medicare Prescription Drug Plan (PDP)

Hospital (inpatient) or skilled nursing facility

Any

Part A

Part A coverage is subject to certain limits; drugs may be covered by Part B or Part D for stays not covered by Part A

Doctor's Office

Vaccines; pneumococcal pneumonia, influenza, and (for intermediate - to high-risk people) Hepatitis B; and some other vaccines related to injury or illness

Part B

All other vaccines

Part D

Injectable/IV drugs given by a doctor and not usually self-administered

Part B

Eligible for Part D coverage if purchased at a pharmacy and administered by a doctor

Home

Drugs that must be administered by Medicare-covered durable medical equipment, e.g., nebulizer or infusion pump

Part B

Long Term Care (LTC)

Drugs that must be administered by Medicare-covered durable medical equipment, e.g., nebulizer or infusion pump

** Drugs are covered under Part D to the extent they are included on the formulary for the person's plan. If a person's drug is not covered, he or she can ask the plan for a coverage determination, but may have to pay full price for that drug. For more information, see "Your Guide to Medicare Prescription Drug Coverage," CMS publication Number 11109, at
http://www.medicare.gov/Publications/Pubs/pdf/11109.pdf

Working with the Office of Health Systems Management, the Medicaid Program has analyzed diagnostic cardiac catheterization procedures at hospitals throughout New York State. A wide variation among
hospitals with respect to the percentage of Medicaid patients who are found to have normal coronary arteries after a diagnostic cardiac catherization procedure was noted.

To ensure that Medicaid patients are receiving high quality care in accordance with national guidelines for evidence-based best practices, the Department of Health will be exploring the extent to which this wide practice variation represents case mix differences or potential overuse or misuse of diagnostic cardiac catheterization. Chart reviews by peer reviewers will be conducted on selected cases.

Additionally, we call your attention to the following national guidelines from the American College of Cardiology and the American Heart Association for management of patients with chronic stable angina and asymptomatic patients with known or suspected coronary artery disease. The guidelines are available on the American College of Cardiology and American Heart Association Web Sites.

Fraker et al. 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to Develop the Focused Update of the 2002 Guidelines for the Management of Patients With Chronic Stable Angina. J. Am. Coll. Cardiol.2007;
50(23):2264-2274 Available at: http://content.onlinejacc.org/cgi/reprint/50/23/2264

It is recognized that patient selection for cardiac angiography at a given hospital depends upon the availability of cardiac surgery capability. The following guideline addresses patient eligibility for diagnostic cardiac catheterization at hospitals with cardiac surgery capability, at hospitals without cardiac surgery capability, and at freestanding laboratories.

Bashore et al. American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J. Am. Coll. Cardiol. 2001; 37(8): 2170-2214